Chapter 3: The Moral Climate of Health Care

Section 2.  Social Context

Health Care System and Values

In order to understand and appreciate the moral climate in health care as the background for examining and thinking about moral dilemmas that arise it is necessary to have some idea of the relevant features of the health care institution within which and against which these moral problems arise and need to be addressed and settled in some fashion. For that to be achieved here , a short examination of some of the more relevant features of the health care system is in order. In what follows but a short sketch is offered. In that sketch the factors that play key roles in the rise of and difficulties with the various moral dilemmas within health care will be presented in a stark and somewhat forceful fashion in order to more quickly arrive at the need for and possible role of ethical principles.

Health Care System

In the advanced technological societies the Health Care System has grown to become a major social institution and an important part of the economy. It is a reflection of the achievement of a society and an indicator of what problems there may be as far as basic quality of life is concerned. Poor health care and poor quality of life or often associated with one another. Any consideration of moral dilemmas must consider the more general background within which situations and problems arise and within which they must be confronted and handled.

Components of the Health Care System:

Providers: primary and secondary (medical schools, professional associations, drug suppliers,etc.. , physicians, nurses, physician assistants, technicians, aids, etc...)

Consumers : patients, family members, companies,

Mechanisms for financing/supporting the institution: direct payment, insurance companies


In examining the values associated with Health Care as an institution some, but not all of the difficulties, that may be termed "moral" begin to appear. While it might appear that in health care the values of health and well being would be quite high it might just be that as an institution there are values held

even higher and oft times in direct conflict with the values held by the human beings who compose health care and are the recipients of health care.

Humanitarian Values

Human beings appear to value as individuals and as such hold as highly desirable that which respects their Freedom, Dignity, Privacy, and Autonomy.

Freedom- people cherish their ability to make decisions and act on them. The human capacity to act (or not to act) as we choose or prefer, without any external compulsion or restraint is what is meant by freedom.

If people are to be held morally accountable for their actions then this sort of freedom is required. If people are compelled to do something or are not permitted to act other than they did they are not held accountable for the moral aspect of the actions. They had no choice and could not have done otherwise. Freedom is having the option to do otherwise.

For such actions as are free people can be and are praised or blamed, rewarded or punished.

The further question of whether choice (the volition or will to act) is itself free or subject to ordinary causality raises the issue of determinism in human conduct. But most modern philosophers have held that

(internal) determination of the will by desire or impulse does not diminish the relevant sense of moral responsibility.

Dignity- To accord humans a sense of worth or esteem is to respect their dignity. Dignity is earned by each individual. Others can recognize, promote, support and encourage and reward those actions by virtue of which a human is thought to be dignified but dignity can not be imposed upon a person. Persons earn it in the ways of others as they make choices as to how they are to live and comport themselves.

Dignity can be denied or even removed from a person when such persons are not permitted to make decisions concerning their own lives nor to carry out their decisions or have them respected and observed by others.

Privacy-Individuals need and desire to have privacy when reflecting and making decisions and often when performing certain actions. Privacy is 1 a : the state of being apart from company or observation. Privacy as a value is to hold it highly desirable to enjoy seclusion or to have the specific freedom from unauthorized intrusion.

This is a state or condition which is often related to autonomy.

Autonomy- people want to be permitted ad encouraged to act on their own in making decisions and to be held accountable for those decisions and for the actions that follow from them. Autonomy is the ability to freely determine one's own course in life.

It is that feature of an individual who makes decisions, rules or laws for the individual's own self. The decision making process should be as unfettered as possible.

An agent acts in an autonomous fashion when the thinking proceeds from internal motivation and uses principles and reasoning that are all internal to the decision maker.

From the Greek 'auto' (self) and 'nomos' (law). Literally 'autonomy' means 'self-rule' and refers to the moral principle which states that every competent moral agent has an intrinsic or social right to determine their own destiny.

According to the principle of autonomy every competent moral agent has a reasonable expectation to be free from unwanted intervention in the disposition of their life.

Economic Values

With a FREE ENTERPRISE system there is a Market System that values profit above all else. Nearly any use of technology is valued in so far as it promotes profit.

Within the social institution of Health Care there are then INSTITUTIONAL VALUES that serve the more general value. In health care as in industry, education and other institutions the principle values are Efficiency and Economy.

The bottom line is income in excess of expenses. With this it does not matter whether it is a doctor's office, laboratory or hospital the focus is on treating as many cases as is possible in a manner that promotes and does not compromise the revenue flow. Treating so many people so fast that it causes harm that brings lawsuits and financial judgments against the institution is not in service to the value of profit. So economy and efficiency are not the unbridled values but operate in terms of the paramount value of profitability.

Doctors' offices, laboratories and hospitals strive to process as revenue sources (cases, clients, customers) as is possible in as short a time as possible. Obtaining the identification data and even more important the information needed to secure payment is an activity of so great an importance as to place it as early in the process of interaction as is possible.

In its normal operations the health care system pits the values of the enterprise and its organization against those of the human beings it is to serve and this results in a tension and gives rise to a whole host of problems and difficulties.

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Copyright Philip A. Pecorino 2002. All Rights reserved.

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